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Palliative Care in the Palliative Care in the Correctional Health Care Correctional Health Care
SettingSetting
Kirk Hochstetler, MDKirk Hochstetler, MDCorrectional Medical ServicesCorrectional Medical Services
Coxsackie Regional Medical UnitCoxsackie Regional Medical Unit
Douglas G. Fish, MDDouglas G. Fish, MDAlbany Medical CollegeAlbany Medical College
Head, Division of HIV MedicineHead, Division of HIV Medicine
August 28, 2008August 28, 2008Washington, DCWashington, DC
ObjectivesObjectives
Changes in HIV morbidity & mortality in Changes in HIV morbidity & mortality in the HAART era.the HAART era.
Defining curative and palliative careDefining curative and palliative care
Care delivery in the correctional settingCare delivery in the correctional setting
Challenges in the correctional settingChallenges in the correctional setting
Estimated Number of AIDS Cases, Deaths, and Persons Living with AIDS,1985-2004,
United States
Note. Data adjusted for reporting delays.
No.
of c
ases
and
dea
ths
(in th
ousa
nds)
Year of diagnosis or death
Prevalence (in thousands)
0 0
90400
450
10
20
50
30
100
40150
50
200
60
250
70
300
80350
19851986198719881989199019911992199319941995199619971998199920002001200220032004
DeathsPrevalence
AIDS 1993 definitionimplementation
CDC
HIV/AIDS Epidemiology in U.S. HIV/AIDS Epidemiology in U.S. Prisons as of 2005Prisons as of 2005
As of December 31, 2005, the following As of December 31, 2005, the following numbers of people were infected with HIV numbers of people were infected with HIV or had AIDS:or had AIDS:– 20,888 State inmates (1.8% of State inmates)20,888 State inmates (1.8% of State inmates)– 1,592 Federal inmates (1% of Federal 1,592 Federal inmates (1% of Federal
inmates) inmates)
This was a slight decrease from 2004 of This was a slight decrease from 2004 of about 450 inmatesabout 450 inmates
HIV in Prisons, 2005 Bureau of Justice Statistics Bulletin, U.S. Dept of Justice, Office of Justice Programs, Sept. 2007; NCJ 218915.
HIV/AIDS in U.S. Prisons: HIV/AIDS in U.S. Prisons: 1999 to 20051999 to 2005
Since 1999, the number of HIV/AIDS State Since 1999, the number of HIV/AIDS State & Federal inmates has decreased overall.& Federal inmates has decreased overall.
27 States reported a decrease in 27 States reported a decrease in HIV/AIDS infected inmates, while 18 State HIV/AIDS infected inmates, while 18 State & Federal prisons reported an increase.& Federal prisons reported an increase.– 5 States and District of Colombia either had 5 States and District of Colombia either had
no change or did not report datano change or did not report data
HIV in Prisons, 2005, Bureau of Justice Statistics Bulletin, U.S. Dept of Justice, Office of Justice Programs, Sept. 2007; NCJ 218915.
Women versus Men Women versus Men with HIV Infectionwith HIV Infection
There are a greater percent of females than There are a greater percent of females than males with HIV infection in the incarcerated males with HIV infection in the incarcerated population.population.
At year end 2005, an estimated 18,953 males At year end 2005, an estimated 18,953 males (1.8%) and 1,935 females (2.4%) in State (1.8%) and 1,935 females (2.4%) in State prisons were HIV-infected or had confirmed prisons were HIV-infected or had confirmed AIDS. AIDS.
The number of cases for both males and The number of cases for both males and females was down from 2004.females was down from 2004.
HIV in Prisons, 2005, Bureau of Justice Statistics Bulletin, U.S. Dept of Justice, Office of Justice Programs, Sept. 2007; NCJ 218915.
Concentration of HIV/AIDS-Concentration of HIV/AIDS-infected Inmates Geographicallyinfected Inmates Geographically
At year end of 2005, half of the HIV/AIDS cases were in the South, nearly a third in the Northeast, and about a tenth in both the Midwest and the West.
The Northeast reported the highest percentage of HIV/AIDS cases based on its custody population (3.9%).
At year end of 2005, three states — New York (4,440), Florida (3,396), and Texas (2,400) — housed nearly half (49%) of all HIV/AIDS cases in State prisons.
HIV in Prisons, 2005, Bureau of Justice Statistics Bulletin, U.S. Dept of Justice, Office of Justice Programs, Sept. 2007; NCJ 218915.
/
HIV-Related Death Rate in New HIV-Related Death Rate in New York State DOCSYork State DOCS
(Rate per 10,000)(Rate per 10,000)
0
5
10
15
20
25
30
35
40
45
HIV
Source: NY State Department of Corrections
Use of HAARTUse of HAART
0
20
40
60
80
100
1996 2002
HAART No HAART
% o
f pa
tient
s
Palella FJ et al. Mortality and morbidity in the HAART era: Changing causes of death and disease in the HIV Outpatient Study. 11th CROI; San Francisco, CA 2004. Abs. 872
55615561 patients in HOPS, 1996-2002patients in HOPS, 1996-2002
19961996 20022002DeathsDeaths– 6.3 /100 person-yrs 6.3 /100 person-yrs 2.2 2.2
OI rates: OI rates: – 23 /100 person-yrs 23 /100 person-yrs 6 6
Reductions in MortalityReductions in Mortality
Palella FJ et al. Mortality and morbidity in the HAART era: Changing causes of death and disease in the HIV Outpatient Study. 11th CROI; San Francisco, CA 2004. Abs. 872
.. and Change in Causes of Death.. and Change in Causes of Death
0102030405060708090
100
1996 2002
Non-HIV related HIV-related
% o
f de
aths
Palella FJ et al. Mortality and morbidity in the HAART era: Changing causes of death and disease in the HIV Outpatient Study. 11th CROI; San Francisco, CA 2004. Abs. 872
Changes in Causes of DeathChanges in Causes of DeathSouthern Alberta, Canada, 1984-2003Southern Alberta, Canada, 1984-2003
0
5
10
15
20
25
30
35
Pre-HAART HAART
7%
32%
Cohort: 1987 patients Total # of deaths= 560
Krents, HB et al. Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada, from 1984 to 2003. HIV Medicine 2005; 6:99–106
% o
f de
aths
, no
n-A
IDS
rel
ated
cau
ses
Increases in Non-AIDS Related Increases in Non-AIDS Related Causes of Death Causes of Death
Southern Alberta, Canada, 1984-2003Southern Alberta, Canada, 1984-2003
Causes of DeathCauses of Death 1984-961984-96 1997-031997-03
Accidental deathsAccidental deaths 2.2%2.2% 17%17%(drug overdose)(drug overdose)
Liver diseaseLiver disease <1<1 8.48.4
Non-HIV CancersNon-HIV Cancers <1<1 77
Krents, HB et al. Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada, from 1984 to 2003. HIV Medicine 2005; 6:99–106
PLWHA Are Getting Older…PLWHA Are Getting Older…NY: HIV/AIDS hospital discharges among PLWHA NY: HIV/AIDS hospital discharges among PLWHA
50 years of age or older50 years of age or older
0
5
10
15
20
25
1994 2003
50 yo/olderSource: SPARCS database, NYSDOH
% o
f H
IV/A
IDS
dis
char
ges
PLWHA Are Getting Older…PLWHA Are Getting Older…
02468
101214161820
1993 2002
50 yo/older
NY: Medicaid Recipients with HIV/AIDS, NY: Medicaid Recipients with HIV/AIDS, Age 50+Age 50+
Source: Medicaid Claims database
% o
f H
IV/A
IDS
rec
ipie
nts
Smoking Prevalence among Smoking Prevalence among PLWHAPLWHA
Prevalence of smoking among people with HIV Prevalence of smoking among people with HIV --- estimated to be --- estimated to be higherhigher than among the than among the general populationgeneral population
New England clinics: More than 70% of HIV+ New England clinics: More than 70% of HIV+ smokesmoke
Swiss HIV Cohort StudySwiss HIV Cohort Study 72% are current/former smokers72% are current/former smokers 96% among IDUs96% among IDUs
Niaura R et al. Smoking among HIV-positive persons. Ann Behav Med 1999; 21(Suppl):S116
Clifford, GM et al. Cancer risk in the Swiss HIV Cohort Study: Associations with immunodeficiency, smoking and Highly Active Antiretroviral Therapy. J Natl Cancer Inst 2005;97:425-432
The Data Collection on Adverse Events of Anti-HIV Drugs (DAD) Study Group, N Engl J Med 2003;349:1993-2003
Incidence of Myocardial Infarction According to the Duration of Exposure to Combination Antiretroviral Therapy
0
2
4
6
8
10
12
14
16
18
20
Anal Hodgkin's Liver
Testicular Melanoma Oropharyngeal
Lung Colorectal
Incidence Rate Ratios of Non-AIDS Incidence Rate Ratios of Non-AIDS Defining MalignanciesDefining Malignancies
1992-20021992-2002
Incidence Rate Ratios of Non-AIDS Incidence Rate Ratios of Non-AIDS Defining MalignanciesDefining Malignancies
1992-20021992-2002Incidence rate ratio Standardized HIV: Observed SEER
HOPS and Adult/Adolescent Spectrum of Disease prospective cohorts
Patel P et al. Incidence of AIDS-defining and non-AIDS defining malignancies among HIV infected persons. CROI 2006
JamesJames
Admitted to Albany Medical Center in May, 2007 Admitted to Albany Medical Center in May, 2007 after outpatient consultationafter outpatient consultationHIV diagnosed in 2000; placed on HAART in HIV diagnosed in 2000; placed on HAART in MayMayCD4+ 108 cells/mmCD4+ 108 cells/mm33
Presented with perianal Herpes in May, 2007Presented with perianal Herpes in May, 2007Developed perirectal fistula with drainage in Developed perirectal fistula with drainage in AugustAugust– Fistulectomy performed without complicationFistulectomy performed without complication
Readmitted in late August with new pneumoniaReadmitted in late August with new pneumonia– Responded well to IV antibioticsResponded well to IV antibiotics
James ReadmittedJames Readmitted
In September he was readmitted with In September he was readmitted with persistent fevers to 105 F.persistent fevers to 105 F.
Liver biopsy and bone marrow consistent Liver biopsy and bone marrow consistent with, but not diagnostic for, malignancy.with, but not diagnostic for, malignancy.
Lymph node biopsy confirmed Hodgkin’s Lymph node biopsy confirmed Hodgkin’s lymphoma.lymphoma.
He adamantly declined chemotherapy.He adamantly declined chemotherapy.
DNR/DNI order requested by patient.DNR/DNI order requested by patient.
James – Regional Medical UnitJames – Regional Medical Unit
Transferred to regional prison hospital in Transferred to regional prison hospital in Coxsackie, New YorkCoxsackie, New York
Coxsackie Regional Medical Coxsackie Regional Medical UnitUnit
Established 1996Established 1996Run by vendor contracted with Run by vendor contracted with NYSDOCSNYSDOCSProvides long term and sub-acute careProvides long term and sub-acute care60 bed male facility60 bed male facilityAdmit patients from Northeast New York Admit patients from Northeast New York population of 22,000 inmatespopulation of 22,000 inmatesApproximately 70,000 inmates in NYApproximately 70,000 inmates in NY
NYS DOCS End of Life NYS DOCS End of Life InitiativeInitiative
Goal is to have Hospice Program in each Goal is to have Hospice Program in each of the 5 Regional Medical Unitsof the 5 Regional Medical Units– 4 Male Facilities (Coxsackie, Wende, Walsh, 4 Male Facilities (Coxsackie, Wende, Walsh,
Fishkill)Fishkill)– 1 Female Facility (Bedford)1 Female Facility (Bedford)– Total of almost 300 beds at presentTotal of almost 300 beds at present– End of life programs in varying stages of End of life programs in varying stages of
development in each RMUdevelopment in each RMU
TerminologyTerminology
TreatmentTreatment
Palliative carePalliative care
Increased Need for Hospice Increased Need for Hospice CareCare
Contributing factorsContributing factors– Longer sentencesLonger sentences– Aging inmate populationAging inmate population– General healthGeneral health
Poor to no healthcare before incarcerationPoor to no healthcare before incarceration
Destructive patterns of behaviorDestructive patterns of behavior
Resistance to access medical care while Resistance to access medical care while incarceratedincarcerated
Higher prevalence of communicable diseaseHigher prevalence of communicable disease
Coxsackie RMU Hospice Coxsackie RMU Hospice ProgramProgram
Contractual component between Contractual component between NYSDOCS and vendor providing health NYSDOCS and vendor providing health care at RMU since 1996care at RMU since 1996
Community Hospice conducted chart Community Hospice conducted chart reviews to demonstrate need and cost reviews to demonstrate need and cost benefit of End of Life servicesbenefit of End of Life services
Hospice program implemented in 1997 Hospice program implemented in 1997 after development of policiesafter development of policies
Coxsackie RMU Hospice Coxsackie RMU Hospice Program Program
1997 - 19981997 - 1998– Focus on education and support services with Focus on education and support services with
FT Hospice RN on siteFT Hospice RN on site– Availability of community-based clergy and Availability of community-based clergy and
social workersocial worker– Involvement with GRACE Project Involvement with GRACE Project (Guiding (Guiding
Responsive Action in Corrections at End-of-Life)Responsive Action in Corrections at End-of-Life)
Selected Enhancements Selected Enhancements Under GRACE Demonstration Under GRACE Demonstration
ProjectProject
Enhance communication and collaboration Enhance communication and collaboration within the facility as well as with various within the facility as well as with various agencies such as Community Hospice, agencies such as Community Hospice, CMS, NYSDOCS, specialty providersCMS, NYSDOCS, specialty providersInmate hospice volunteer programInmate hospice volunteer programProvide further orientation, training and Provide further orientation, training and ongoing education for CMS and DOC staffongoing education for CMS and DOC staff
Coxsackie RMU Hospice Coxsackie RMU Hospice ProgramProgram
1998 - 20001998 - 2000– 16 hour/week Community Hospice RN onsite16 hour/week Community Hospice RN onsite– Participation in patient care conferenceParticipation in patient care conference– Hospice availability for consultations and Hospice availability for consultations and
concurrent chart reviewconcurrent chart review– DON and 2 Nurse Practitioners received DON and 2 Nurse Practitioners received
HPNA certificationHPNA certification
Coxsackie RMU Hospice Coxsackie RMU Hospice ProgramProgram
2000 - present2000 - present– Community Hospice utilized as consultant Community Hospice utilized as consultant
service for difficult cases and quarterly chart service for difficult cases and quarterly chart reviewreview
– In-house Case ManagerIn-house Case Manager– Inmate Hospice Aide ProgramInmate Hospice Aide Program– Incorporated Hospice into employee orientationIncorporated Hospice into employee orientation– Cross collaboration between Medical Director Cross collaboration between Medical Director
and Community Hospice Directorand Community Hospice Director
Coxsackie RMU Statistics Coxsackie RMU Statistics Total (HIV)Total (HIV)
20042004 20052005 20062006
Admissions (HIV) 58 (15)Admissions (HIV) 58 (15) 64 (16)64 (16) 60 (14)60 (14)
Total DischargesTotal Discharges 56 (15) 56 (15) 65 (14) 65 (14) 63 (13)63 (13)
ParoledParoled 17 (6)17 (6) 21 (8)21 (8) 27 (3)27 (3)
Transferred Transferred 19 (4) 19 (4) 22 (2)22 (2) 16 (2)16 (2)
Expired Expired 20 (5)20 (5) 22 (4)22 (4) 20 (8)20 (8)
Hospice DeathsHospice Deaths 15 (4)15 (4) 14 (4)14 (4) 13 (8)13 (8)
Non-Hospice DeathsNon-Hospice Deaths 5 (1)5 (1) 8 (0)8 (0) 7 (0)7 (0)
% Hospice Deaths% Hospice Deaths 75% (80%)75% (80%) 64% (100%)64% (100%) 65% (100%)65% (100%)
Top 3 Diagnoses:Top 3 Diagnoses:– CancerCancer– End stage liver disease/Hepatitis CEnd stage liver disease/Hepatitis C– HIV/AIDSHIV/AIDS
Challenges Unique to Hospice Challenges Unique to Hospice Behind BarsBehind Bars
Changing PhilosophyChanging Philosophy
AcceptanceAcceptance
Pain ManagementPain Management
Psycho-Social Psycho-Social SupportSupport
Trust IssuesTrust Issues
VisitationVisitation
Consultant Consultant CommunicationCommunication
Advanced DirectivesAdvanced Directives
Comfort FoodComfort Food
Medical ParoleMedical Parole
Discharge PlanningDischarge Planning
Alternative TreatmentAlternative Treatment
Security ConcernsSecurity Concerns
Compassion Without Compassion Without PrejudicePrejudice
BereavementBereavement
Changing PhilosophyChanging Philosophy
People will die while incarceratedPeople will die while incarcerated
Everyone has the right to a “good death”Everyone has the right to a “good death”
It’s the right thing to doIt’s the right thing to do
Level of health care mirrors that in Level of health care mirrors that in communitycommunity
Inmate vs. patientInmate vs. patient
Patient directed carePatient directed care
AcceptanceAcceptance
Patient acceptance of diagnosis and Patient acceptance of diagnosis and possibility of dying in prisonpossibility of dying in prison
Patient acceptance of care from inmate Patient acceptance of care from inmate volunteervolunteer
Patient acceptance of medical carePatient acceptance of medical care
Staff acceptance of inmate as a patientStaff acceptance of inmate as a patient
Security acceptance of compassionate Security acceptance of compassionate care for an inmatecare for an inmate
Pain ManagementPain Management
Trusting patient’s pain ratingTrusting patient’s pain rating
Drug seeking vs. drug resistanceDrug seeking vs. drug resistance
DiversionDiversion
VictimizationVictimization
Route of deliveryRoute of delivery
Availability of medicationAvailability of medication
High doses needed to control pain in IVDUHigh doses needed to control pain in IVDU
Psychosocial SupportPsychosocial Support
IsolationIsolation
FamilyFamily
““Family”Family”
Lack of controlLack of control
Manipulation as a form of controlManipulation as a form of control
Poor social skillsPoor social skills
Mental healthMental health
Disclosure, confession and forgivenessDisclosure, confession and forgiveness
Trust IssuesTrust Issues
Accurate medical informationAccurate medical information
Patient with medical staffPatient with medical staff
Family with medical staffFamily with medical staff
Security with medical staffSecurity with medical staff
Patient with securityPatient with security
Patient with other inmatesPatient with other inmates
VisitationVisitation
DistanceDistance
ResourcesResources
Contacting family and friendsContacting family and friends
Alienation of patient from familyAlienation of patient from family
Patient reluctancePatient reluctance
Visitor clearanceVisitor clearance
Closure and death bed visitClosure and death bed visit
Consultant CommunicationConsultant Communication
Lack of understanding of how DOC worksLack of understanding of how DOC works
Offering treatments not allowed by DOCOffering treatments not allowed by DOC
Lack of understanding of RMU capabilityLack of understanding of RMU capability
Acceptance of treatment planAcceptance of treatment plan
Adopting Hospice philosophyAdopting Hospice philosophy
Advanced DirectivesAdvanced Directives
Reluctance of physicians to discussReluctance of physicians to discuss
Addressed with every RMU patientAddressed with every RMU patient
Offers patient control over careOffers patient control over care
Not required for Hospice careNot required for Hospice care
Belief that DNR means no careBelief that DNR means no care
Attempt to not die in prisonAttempt to not die in prison
Availability of Health Care ProxyAvailability of Health Care Proxy
Patient without capacityPatient without capacity
Comfort FoodComfort Food
Standardization of mealsStandardization of meals
Limited commissary choicesLimited commissary choices
Family unable to bring in foodFamily unable to bring in food
Staff unable to bring in foodStaff unable to bring in food
Formalized process establishedFormalized process established
Viewed as special treatment by securityViewed as special treatment by security
Meal requests available on approvalMeal requests available on approval
Medical ParoleMedical Parole
Criteria very stringentCriteria very stringent
Multiple applicationsMultiple applications
Processing period - timing is everythingProcessing period - timing is everything
Initiation of process at time of diagnosisInitiation of process at time of diagnosis
Initiate before admissionInitiate before admission
Crime restrictive discharge planningCrime restrictive discharge planning
Patient expires during processPatient expires during process
Medical Parole/FBCRMedical Parole/FBCR
Medical Parole – for those inmates who Medical Parole – for those inmates who have not yet been to their first board have not yet been to their first board appearanceappearance
* excludes conviction for murder 1 or 2* excludes conviction for murder 1 or 2
* excludes conviction for any sex crime* excludes conviction for any sex crime
Full Board Case Review – for those inmates Full Board Case Review – for those inmates who have already been to the board oncewho have already been to the board once
* have met minimal time requirement* have met minimal time requirement
NYSDOCS: Medical Paroles Requested NYSDOCS: Medical Paroles Requested & Granted (All Diagnoses)& Granted (All Diagnoses)YearYear # Requested# Requested # Granted# Granted19941994 255255 5252
19951995 238238 6060
19961996 209209 4444
19971997 9898 2121
19981998 8989 1414
19991999 8484 1717
20002000 8282 1212
20012001 150150 2020
20022002 100100 1414
20032003 119119 2222
20042004 113113 1212
20052005 8787 1212
20062006 7979 1414
20072007 6767 1212
Source: NYSDOCS, November 2007
NYSDOCS: HIV/AIDS Medical NYSDOCS: HIV/AIDS Medical Paroles Requested & GrantedParoles Requested & Granted
YearYear # Requested# Requested # Granted# Granted19941994 191191 4545
19951995 179179 5858
19961996 149149 3939
19971997 5555 1616
19981998 4444 55
19991999 2626 55
20002000 1717 33
20012001 3434 55
20022002 2525 88
20032003 1616 44
20042004 1616 33
20052005 88 11
20062006 44 22
20072007 55 11
Source: NYSDOCS, November 2007
NYSDOCS: Medical ParolesNYSDOCS: Medical Paroles
106/797 granted statewide since 2000106/797 granted statewide since 2000
27/125 HIV+ inmates granted since 200027/125 HIV+ inmates granted since 2000
Medical Parole/FBCRMedical Parole/FBCR
2001 to present:2001 to present:- - 114 patients submitted for MP/FBCR114 patients submitted for MP/FBCR
27 denied (24%)27 denied (24%)49 expired (43%)49 expired (43%)38 released (33%)38 released (33%)
– 106 released statewide (36% from Coxsackie RMU)106 released statewide (36% from Coxsackie RMU)
– 32 HIV patients submitted for MP/FBCR32 HIV patients submitted for MP/FBCR3 denied (9%)3 denied (9%)14 expired (44%)14 expired (44%)15 released (47%)15 released (47%)
– 24 released statewide (62% from Coxsackie RMU)24 released statewide (62% from Coxsackie RMU)
Discharge Planning and Discharge Planning and Follow-Up CareFollow-Up Care
Limited choicesLimited choices
Acceptance of and continuity of treatment Acceptance of and continuity of treatment planplan
Reliance on paroleReliance on parole
Crime and diagnosis restrictiveCrime and diagnosis restrictive
Limited family contact/involvementLimited family contact/involvement
Are they better off in prison?Are they better off in prison?
Alternative TreatmentsAlternative Treatments
Very restricted in correctional settingsVery restricted in correctional settings
Modified touchingModified touching
Medical approval to obtain homeopathic Medical approval to obtain homeopathic treatmenttreatment
Spiritual SupportSpiritual Support
Spiritual support limited by religions Spiritual support limited by religions represented by DOCrepresented by DOC
Disclosure, confession and forgivenessDisclosure, confession and forgiveness
Limited opportunities for fellowshipLimited opportunities for fellowship
Inmate hospice aide and volunteersInmate hospice aide and volunteers
Group effort - not limited to clergyGroup effort - not limited to clergy
Security ConcernsSecurity Concerns
Patient manipulation of systemPatient manipulation of system
Distribution of narcoticsDistribution of narcotics
Equipment needed to take care of patientsEquipment needed to take care of patients
Limited understanding of infection controlLimited understanding of infection control
Family visitsFamily visits
In-room vs. visiting room visitsIn-room vs. visiting room visits
Body/room searchBody/room search
Compassion without Compassion without PrejudicePrejudice
The patient who refuses care for The patient who refuses care for underlying diseaseunderlying disease
Seeing the person, not the crimeSeeing the person, not the crime
Maintaining respect of patientMaintaining respect of patient
Conflicting emotionsConflicting emotions
BereavementBereavement
Limited family contactLimited family contact
Reliance on Community HospiceReliance on Community Hospice
Imposed relief time for IHAImposed relief time for IHA
Onsite social worker for 1:1 counselingOnsite social worker for 1:1 counseling
Memorial services offered to patients and Memorial services offered to patients and staffstaff
After Death ChallengesAfter Death Challenges
Family not allowed to view body at facilityFamily not allowed to view body at facility
DOC autopsy requirementsDOC autopsy requirements
Next of kin notificationNext of kin notification
Closure obstaclesClosure obstacles– cost of funeralcost of funeral– burial on state groundsburial on state grounds– limited family contact after deathlimited family contact after death
JamesJamesRMU evaluation started prior to admissionRMU evaluation started prior to admission
Admission evaluationAdmission evaluation– Pain assessmentPain assessment– Education levelEducation level– Request to continue DNRRequest to continue DNR– Declined chemotherapy/radiation therapyDeclined chemotherapy/radiation therapy– ““My T-cells are too low and the chemo will eat My T-cells are too low and the chemo will eat
them up”them up”– Presented with information on Hospice programPresented with information on Hospice program
JamesJames
Evaluated by:Evaluated by:– Admitting RNAdmitting RN– Nurse PractitionerNurse Practitioner– Hospice Coordinator (DON)Hospice Coordinator (DON)– PhysicianPhysician– Social WorkerSocial Worker– NutritionistNutritionist– DOC Guidance CounselorDOC Guidance Counselor– ClergyClergy
JamesJames
Unplanned family visit the day after Unplanned family visit the day after admissionadmission
Family given information on Hospice Family given information on Hospice ProgramProgram
Patient agreed to and signed for Hospice Patient agreed to and signed for Hospice one week after admissionone week after admission
Inmate Hospice volunteers scheduledInmate Hospice volunteers scheduled
JamesJames
Clinically, James was not able to tolerate Clinically, James was not able to tolerate medications due to renal involvementmedications due to renal involvement
As his condition declined, treatment As his condition declined, treatment medications were stoppedmedications were stopped
Palliative medications continuedPalliative medications continued– Pain medicationPain medication– Anxiety medicationAnxiety medication
JamesJames
Three days after signing for Hospice, Three days after signing for Hospice, James became confused, obtundedJames became confused, obtundedEnd-of-Life orders writtenEnd-of-Life orders writtenFamily notified of change in conditionFamily notified of change in conditionInmate Hospice Volunteer 24 hour vigil Inmate Hospice Volunteer 24 hour vigil startedstartedJames expired about 3 hours after family James expired about 3 hours after family visitvisit
Federal Bureau of PrisonsFederal Bureau of Prisons
Federal Bureau of Prisons Federal Bureau of Prisons Hospice ProgramHospice Program
The Federal Bureau of Prisons (BOP) has had hospice The Federal Bureau of Prisons (BOP) has had hospice programs since the late 1980s.programs since the late 1980s.
The first BOP Hospice Program started at the Medical The first BOP Hospice Program started at the Medical Center for Federal Prisoners in Springfield, Missouri in Center for Federal Prisoners in Springfield, Missouri in 1987. 1987.
Currently the Bureau of Prisons has Hospice/Palliative Currently the Bureau of Prisons has Hospice/Palliative Care Programs at 5 Federal Medical Centers (FMC): Care Programs at 5 Federal Medical Centers (FMC): FMC Butner, FMC Carswell, FMC Lexington, FMC FMC Butner, FMC Carswell, FMC Lexington, FMC Rochester and MCFP Springfield. Rochester and MCFP Springfield. – As of October 2007, 52 inmates were in hospice programs As of October 2007, 52 inmates were in hospice programs
at these locations.at these locations.
Correspondence with Julia Dunaway, Chief Social Worker at the Federal BOP, November 2007
Federal Bureau of Prisons Federal Bureau of Prisons Hospice ProgramHospice Program
An appropriate hospice referral generally An appropriate hospice referral generally includes any patient who has been includes any patient who has been diagnosed with a terminal illness and diagnosed with a terminal illness and given a life expectancy of 1 year or less.given a life expectancy of 1 year or less.
Patient is eligible to apply forPatient is eligible to apply forCompassionate Release Procedures for Compassionate Release Procedures for Implementation.Implementation.
Correspondence with Julia Dunaway, Chief Social Worker at the Federal BOP, November 2007
Federal Bureau of Prisons Federal Bureau of Prisons Hospice ProgramHospice Program
A unique characteristic of BOP Hospice/Palliative A unique characteristic of BOP Hospice/Palliative Care Programs is the use of inmate volunteers. Care Programs is the use of inmate volunteers.
Volunteers typically receive training based on Volunteers typically receive training based on national hospice standards, consisting of 30 hours national hospice standards, consisting of 30 hours of annual instruction. of annual instruction.
Training is often taught by both BOP staff and Training is often taught by both BOP staff and community professionals. community professionals.
Correspondence with Julia Dunaway, Chief Social Worker at the Federal BOP, November 2007
The GRACE Project (Guiding Responsive The GRACE Project (Guiding Responsive Action in Corrections at End-of-Life)Action in Corrections at End-of-Life)
Collected information on end-of-life programs Collected information on end-of-life programs in Federal BOP and 14 state DOC systems.in Federal BOP and 14 state DOC systems.
Analyzed challenges to providing quality end Analyzed challenges to providing quality end of life care in corrections settings of life care in corrections settings
Compiled best practice program Compiled best practice program
componentscomponentsRatcliff, 2000, Jackie Zalumas, Ph.D., RNC, FNP, Corrections Technical Assistance and Training Project Southeast AETC, 2005
Positive outcomes: National Institute of CorrectionsPositive outcomes: National Institute of Corrections(NIC) study in 1997(NIC) study in 1997
Advantages of hospice approach in the correctionsAdvantages of hospice approach in the correctionsenvironment:environment:
Improved quality of life/experience of deathImproved quality of life/experience of death
Improved quality of medical careImproved quality of medical careBenefits to staff and inmatesBenefits to staff and inmatesBenefits to inmates’ families and friendsBenefits to inmates’ families and friendsCost benefits - decreased trips to outside hospitalsCost benefits - decreased trips to outside hospitalsDecreased security issuesDecreased security issuesGood public relations with communityGood public relations with community
Positive Outcomes
Jackie Zalumas, Ph.D., RNC, FNP, Corrections Technical Assistanceand Training Project Southeast AETC, 2005
Increase in End-of-life Programs Increase in End-of-life Programs in Correctionsin Corrections
30 months after NIC survey, the GRACE Project 30 months after NIC survey, the GRACE Project conducted a new inventory of correctional hospice conducted a new inventory of correctional hospice and palliative care programs.and palliative care programs.– Number of states with end-of-life programs in place or under Number of states with end-of-life programs in place or under
development doubled. development doubled. – Number of states with at least one hospice program in place Number of states with at least one hospice program in place
increased from 11 to 19 . increased from 11 to 19 . – Number of states with an end-of-life program under development had Number of states with an end-of-life program under development had
gone from 4 to 14. gone from 4 to 14. – 9 states with programs in place had plans for additional 9 states with programs in place had plans for additional
programs.programs.
Ratcliff, 2000, Jackie Zalumas, Ph.D., RNC, FNP, Corrections Technical Assistance and Training Project Southeast AETC, 2005
National Prison Hospice National Prison Hospice AssociationAssociation
Provides general guidelines that aim to assist Provides general guidelines that aim to assist administrators and health care providers in the administrators and health care providers in the development and maintenance of prison-based hospice development and maintenance of prison-based hospice programs. programs.
Operational guidelines provide a broad outline of: Operational guidelines provide a broad outline of:
(1) Essential concepts of hospice and palliative care(1) Essential concepts of hospice and palliative care
(2) Unique policy issues confronting those who must (2) Unique policy issues confronting those who must adapt this approach to the correctional settingadapt this approach to the correctional setting
(3) Procedures for creating a facility-specific manual(3) Procedures for creating a facility-specific manual for a prison hospice/palliative care programfor a prison hospice/palliative care program
National Prison Hospice Association, 2007
National Prison Hospice National Prison Hospice AssociationAssociation
PO BOX 4623PO BOX 4623BOULDER, CO 80306-4623BOULDER, CO 80306-4623
303-447-8051303-447-8051
[email protected]@npha.org
SummarySummary
The face of the AIDS epidemic has The face of the AIDS epidemic has changed in the last 27 years.changed in the last 27 years.
Availability of hospice in the prison setting Availability of hospice in the prison setting is recognition of the importance of dying is recognition of the importance of dying with dignity.with dignity.
Palliative/hospice care benefits the patient, Palliative/hospice care benefits the patient, available family, and the corrections available family, and the corrections staff.staff.
AppreciationAppreciationAlvaro Carrascal, M.D. NY State D.O.H. AIDS InstituteAlvaro Carrascal, M.D. NY State D.O.H. AIDS InstituteJulia Dunaway, Chief Social Worker, Federal Bureau of Julia Dunaway, Chief Social Worker, Federal Bureau of PrisonsPrisonsLou Smith, M.D. NY State Bureau of HIV/AIDS, NY State Lou Smith, M.D. NY State Bureau of HIV/AIDS, NY State D.O.H.D.O.H.Sarah Walker, M.S. Albany Medical College, Division of Sarah Walker, M.S. Albany Medical College, Division of HIV Medicine, for her assistance in gathering some of HIV Medicine, for her assistance in gathering some of the data.the data.Lester Wright, M.D., M.P.H. NY State Dept. of Lester Wright, M.D., M.P.H. NY State Dept. of Correctional ServicesCorrectional ServicesJackie Zalumas, Ph.D., RNC, F.N.P. Southeast AIDS Jackie Zalumas, Ph.D., RNC, F.N.P. Southeast AIDS Training and Education CenterTraining and Education Center
Thank You!Thank You!